Transcript Acute Care of the Hospitalized Elderly Patient

Acute Care of the Hospitalized
Elderly Patient
Rosanne M. Leipzig, MD PhD
Patricia Bloom MD
Helen Fernandez MD
Brookdale Department of Geriatrics
Mount Sinai School of Medicine
Why This Talk?
42%
45%
37%
40%
35%
30%
25%
20%
15%
10%
13%
5%
0%
Population
Hospital Admissions
Hospital Days
Adults Over 65 years Old
National Hospital Discharge Survey 2007
Fernandez, H. and Callahan, K
Functional Status:
Activities of Daily Living (ADLs)
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ADLs
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Dressing
Eating
Ambulation
Transfer
Hygiene
• Bathing
• Toileting

Instrumental ADLS
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



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Telephone use
Getting to places beyond
walking distance
Grocery shopping
Preparing meals
Housework/handyman
work
Taking medications
Managing money
Outcomes of Acute Care for
Older Adults

Early 1990’s (5 sites):

31% lose >1 basic ADL at discharge c/w pre-admission
• 2/5 of these remained impaired 3 months later
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40% have IADL decline at 3 months
1998-2008

42% lose >1 basic ADL at discharge c/w pre-admission (1 site)
• 6 months later



23.3% non-recovered
17.4% dead
Similar initial declines in Israel, Italy
Sager M et al:Arch Intern Med. 1996 Mar 25;156(6):645-52.;
Barry LC et al: JAGS 2011; DOI: 10.1111/j.1532-5415.2011.03453.x
New Admission, RF

82 year old female admitted for left humeral
fracture after fall. Asymptomatic except for pain.
 H/O HTN, CHF, osteoarthritis, osteoporosis,
depression
 Meds:




Lisinopril 10 mg qd,
Furosemide 20 mg qd
Paroxetine 20 mg qd
Ibuprofen 400 mg tid prn
Atenolol 25 mg qd
Vitamin D 1000 IU qd
Calcium 500 mg tid
Alendronate 70 mg
once a week
New Admission

Lives alone; nonsmoker, nondrinker
 Exam
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110/80, 80, 16, 37.5 C, Wt: 100 lb
Alert and oriented x 3
HR 80, reg; no m/g/r
Chest clear to P+A
Abdomen soft, NT
No CCE
L upper extremity in sling- painful to active or passive
motion
Foley and IV catheter in place
Admitting Orders
 Admit
to ……
 Dx: L Humeral fracture
 Activity:
 Diet:
Admitting Orders
 Admit
to ……..
 Dx: Left humeral fracture
 Activity: Bed Rest
Usual Aging
Creditor, M. C. Ann Intern Med 1993;118:219-223
Bed Rest and Hospitalization are Dangerous
to the Health of Older Adults
Bed Rest
Creditor, M. C. Ann Intern Med 1993;118:219-223
Bed Rest and Hospitalization are Dangerous
to the Health of Older Adults
•Loss of strength/day at bed rest
•Football players:1-1.5% strength/day (10%/week)
•Elderly patients: 5%/day (35%/week)
•Reconditioning takes much longer than deconditioning
Creditor, M. C. Ann Intern Med 1993;118:219-223
Bed Rest and Hospitalization are Dangerous
to the Health of Older Adults
•Bone resorption of elderly acutely ill person at bedrest
50 TIMES usual involutional rate
Creditor, M. C. Ann Intern Med 1993;118:219-223
Bed Rest and Hospitalization are Dangerous
to the Health of Older Adults
•Usual Aging: pO2 = 90 – (age over 60)
• Costochondral calcification and reduced muscle strength
diminish pulmonary compliance and increase RV
•Bed rest (supine position) decreases pO2 by 8 mm on average
•Closing volume increases, more alveoli hypoventilated
•pO2 for an 80 year old:
• Normal:
70
Creditor, M. C. Ann Intern Med 1993;118:219-223
• At bedrest: 62
Bed Rest and Hospitalization are Dangerous
to the Health of Older Adults
•Skin necrosis results from direct pressure > capillary filling
pressure (=32 mmHg) for more than 2 hours
•Sacral pressure after short immobilization=70 mm
•Increased likelihood of shearing forces and exposure to
moisture increase risk of skin breakdown
•Pressure ulcer prevalence 20-25%
Creditor, M. C. Ann Intern Med 1993;118:219-223
Admitting Orders
 Admit
to
 Dx: Left humeral fracture
 Activity: Bed Rest
Bed Rest is Only
Good for Dead People
and a Few Others
Admitting Orders
 Admit
to …
 Dx: Left humeral fracture
 Activity: Out of bed to chair; ambulate with
assistance day and evening shift
 Diet: NPO for surgery
 Foley catheter to closed drainage
 IV: D5/0.5NS at 75 cc/hr
CTSP for
 Temp
38.5, HR 130 irreg, irreg and SOB
 Exam: BP 110/70; RR 20; right posterior
rales
 CXR: possible RLL infiltrate
 EKG shows MFAT
 Medicine consult called
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Surgery held
IV antibiotics started
Orders
 Admit
to ……
 Dx: Left humeral fracture
 Activity: Out of bed to chair; ambulate with
assistance day and evening shift
 Foley catheter to closed drainage
 IV levofloxacillin
 Diet: NPO for surgery
What Diet Should be prescribed
for Ms RF?
 A)
Regular diet
 B) No added salt
 C) 2 gm Na+
Bed Rest and Hospitalization are Dangerous
to the Health of Older Adults
• Sense of taste decreases with age
–Hospital food often tasteless
–Decreased intake if not salted or seasoned
• 25-30% of hospitalized elderly are under/malnourished
• Under/malnutrition a strong negative predictor of clinical
outcome
• Readily available markers:
–Serum albumin (after rehydration- ck the Hb)
–TLC
(WBC x lymph %) (WNL=2000+)
Creditor, M. C. Ann Intern Med 1993;118:219-223
Bed Rest and Hospitalization are Dangerous
to the Health of Older Adults
•Older adults tend toward intravascular dehydration
•Thirst is less for degree of hyperosmolarity
•Renal concentrating ability often impaired
•Salt wasting increases
Creditor, M. C. Ann Intern Med 1993;118:219-223
Orders
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
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


Admit to……
Dx: Left humeral fracture
Activity: Out of bed to chair; ambulate with
assistance day and evening shift
Foley catheter to closed drainage
IV Levofloxacin
Diet: Regular; monitor food intake
Benedryl 25 mg prn sleeplessness
CTSP for
 Agitation,
trying to get out of bed and
attempting to pull out foley and IV
 Exam unchanged from before except more
confused
 What’s going on?
Bed Rest and Hospitalization are Dangerous
to the Health of Older Adults
Creditor, M. C. Ann Intern Med 1993;118:219-223
Delirium -- DSM-IV
A. Disturbance of Consciousness
• Reduced ability to focus, sustain, shift attention
B. Cognitive Change
•
•
•
•
Memory
Perception (Hallucinating, Delusions, Illusions)
Disorientation
Language Disturbances
C. Develops over time
D. Fluctuates during the course of the day
Distinguishing Delirium from
Dementia
Delirium
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Abrupt, precise onset
Acute illness (days to
weeks), rarely over one
month
Usually reversible
Variability hour-to-hour
Disturbed sleep-wake
cycle, (hour-to-hour )
Dementia

Gradual onset
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Chronic Illness, progressing over
years
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Generally irreversible
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Generally more stable
Day-night reversal of sleep-wake
cycle
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Distinguishing Delirium from
Dementia (cont’d)
Delirium
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Dementia
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
Clouded, altered, changing
level of consciousness
Short attention span
Disorientation early

Hallucinations early
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Hallucinations late (except
with hearing or visual
problems or delirium)
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Marked psychomotor
changes
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Psychomotor changes late
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Consciousness not clouded
until terminal
Normal Attention span
Disorientation late, after
months or years
Delirium in Elderly Hospitalized
Patients: Morbidity and Mortality
 Increased
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Mortality
Institutionalization
Length of Stay
Physical and Chemical Restraints
•
•
•
•
•
Pressure Ulcers
Dehydration
Aspiration
Malnutrition
Deconditioning
Ref: Inouye SK. NEJM 2006;354:1157-65
Delirium in Hospitalized Elderly
Predisposing Factors
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Severe Illness, co-existing medical conditions
Dementia and Structural Brain Disease, h/o
delirium, depression
Advanced Age
Impaired functional status
Impaired Hearing or Vision
Decreased oral intake (dehydration,
malnutrition)
Drugs (multiple, esp psychotropic; alcohol)
Ref: Inouye SK. NEJM 2006;354:1157-65
Delirium in Hospitalized Elderly
Precipitating Factors
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Drugs:
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sedative hypnotics, narcotics, anticholinergics,
alcohol withdrawal, treatment with multiple drugs
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Primary neurologic disease
 Intercurrent illnesses
 Surgery
 Environmental
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
Physical restraints, bladder catheter, pain, multiple
procedures, stress
Prolonged sleep deprivation
Ref: Inouye SK. NEJM 2006;354:1157-65
Delirium in Hospitalized Patients
Validation Cohort
Predisposing Factors
Precipitating Factors
Inouye and Charpentier JAMA. 1996 Mar 20;275(11):852-7
Confusion Assessment Method
(CAM) for Diagnosing Delirium
 Both
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Acute onset and fluctuating course
Inattention
 And
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
either
Disorganized thinking, or
Altered level of consciousness
Inouye et al. Ann Intern Med 1990;113:941-948.
CAM: Test Characteristics
12 studies pooled
 Sensitivity:
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86% (74-93)
 Specificity:

+
Likelihood Ratio:

-
93% (87-96)
9.6 (5.8-16.0)
Likelihood Ratio:

0.16 (0.09-0.19)
Wong CL et al JAMA 2010; 304(7):779-786
MMSE Tests of Attention
in Cognitively Intact Subjects
 Serial

7s (79)
43.5% with 5/5 correct
 WORLD

backwards
74.1% correct
Ganguli M. et al. J Geriatr Psychiatry Neurol. 1990;3(4):203-7.
Attention and Concentration
Assessment
 Serial
7s
 Cancellation tasks
 Random digits, forwards/backwards
 Months of the year, days of the week,
forwards/backwards
CONFFUSED
C- entral Nervous System
O- rgan Dysfunction
N- utrition
F- ever
F- luids and Electrolytes
U- rine infection, retention
S- ensory over- or under- stimulation
E- ndocrine Disorders
D- rugs- including withdrawal
Leipzig RM 1992
Drugs Commonly Causing Delirium
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Alcohol, other sedative/hypnotics
Anticholinergics (diphenhydramine, tricyclics,
cimetidine, theophylline)
Opioid analgesics (esp meperidine)
Corticosteroids
Antihypertensives/cardiac drugs
Antiparkinsonian drugs
Psychoactive drugs (anxiolytics, hypnotics)
Delirium Evaluation
1. CONFFUSED
2. Target Labs

CBC, SMA.6, Creatinine, Calcium, Phosphate, LFTs
3. Search for Occult infection: CXR, UA
4. Consider


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ABGs, EKG, LP, CT/MRI
Mg, TFTs, B12, Drug Levels, Ammonia, Tox Screen
EEG
Ref: Inouye SK. NEJM 2006;354:1157-65
Treatment of Delirium
 Treat

Stop offending medications
 Use



underlying medical problem
environmental interventions
Reduce isolation, reassurance, conversation
Identify precipitants
Maximize safety
 Restrain
or use low dose antipsychotics
ONLY when absolutely necessary
Antipsychotics:
Weighing the Benefits vs Risks
Ref: Image retrieved on 29 June 2011 from: http://office.microsoft.com/en-us/images/MM900283494.aspx
Black Box Warning: June 16, 2008
 Antipsychotics
are not indicated for the
treatment of dementia-related psychosis.
 Elderly patients with dementia-related
psychosis treated with conventional or
atypical antipsychotic drugs are at an
increased risk of death.
Antipsychotics and Mortality

Both atypical and typical antipsychotics
 Occur early in course of treatment
 For atypicals, NNH= 100 (50- 250)

No differences in risk by:
• specific drug
• severity of dementia
• diagnosis.

For typicals, risk was greatest
• During the first 40 days
• higher doses
Schneider LS, Dagerman KS, Insel P. JAMA. 2005; 294 (15): 1934-1943. Wang PS,
Schneeweiss S, Avorn J, et al. N Engl J Med. 2005; 353(22):2335-2341.
Black Box Warning: June 16, 2008

Antipsychotic drugs are not approved for the
treatment of dementia-related psychosis.
 Furthermore, there is no approved drug for the
treatment of dementia-related
psychosis. Healthcare professionals should
consider other management options.
 Physicians who prescribe antipsychotics to
elderly patients with dementia-related psychosis
should discuss this risk of increased mortality
with their patients, patients’ families, and
caregivers
When Should Antipsychotics Be
Prescribed in Dementia?

When severe symptoms cause suffering for
the patient, disrupting needed care, and/or
leading to danger, benefits may outweigh
risk.
 Document:


your evaluation of the benefits and risks for the
specific patient
your discussion with family and conclusion that
the potential benefits outweigh the potential
risks, including those of CVAEs and increased
mortality.
AGS 2011: Guide to the Management of psychotic disorders and neuropsychiatric
symptoms of dementia in older adults
Antipsychotic Drugs of Choice for
Delirium

Haloperidol (Haldol)
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Risperidone (Risperdal)
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Starting dose : 1-2 mg po or 0.5-1 mg IM/IV
Average dose/24 hrs : 1.5 – 2 mg IM/IV
Starting dose : 0.25 – 0.5 mg po
Average dose/24 hrs : 0.5 – 1.5 mg
Olanzapine (Zyprexa)


Starting dose : 2.5 – 5 mg
Average dose/24 hrs : 5 – 7.5 mg
Restraints

Lead to all the hazards of immobilization, plus
increased agitation, depression, and injury
 Restraints do NOT decrease falls (may increase
by increasing deconditioning*)
 JAHCO Acute Med/Surg Standard for
Restraints:


Applied when a restraint is necessary for the patient’s
wellbeing and can be used to improve medical care
All patients have the right to the least restrictive
environment of care
•Tinetti ME et al. Ann Intern Med. 1992 ;116(5):369-74;
•Capezuti E, et al; J Gerontol A Biol Sci Med Sci. 1998 Jan;53(1):M47-52.
Alternatives to Use of Restraints
and Antipsychotics
 Increase
nursing surveillance
 Involve family and friends
 Modify medications if problematic
 Reality orientation, explanation,
reassurance
 Improve hearing and vision
 Modify environment to increase safety
 Reconsider NG tubes, IVs and catheters
Orders
 Admit
to……
 Dx: Left humeral fracture
 Activity: Out of bed to chair; ambulate with
assistance day and evening shift
 Diet: Regular; monitor food intake
 Foley catheter to closed drainage
Orders
 Admit
to……
 Dx: Left humeral fracture
 Activity: Out of bed to chair; ambulate with
assistance day and evening shift
 Diet: Regular; monitor food intake
 IV: Levofloxacin qd
 Levofloxacin qd po
Hospital Course
 Patient’s
pneumonia and delirium respond
to antibiotics and she has surgery 5 days
later
 Postoperatively does well
Orders
 Admit
to……
 Dx: Left humeral fracture
 Activity: Ambulate with walker
 Diet: Regular; monitor food intake
 IDP (Initiate Discharge Planning)
 Medication Reconcilliation
TEN COMMANDMENTS of Care for the
Hospitalized Elderly
1)
2)
3)
4)
5)
Bed Rest is for Dead People and a few others.
GET THE PATIENT MOVING!!!
The fewer drugs, the better. Review meds
frequently.
Get out IV lines and catheters as soon as
possible.
Avoid restraints whenever possible.
Assess and monitor mental/cognitive status
DAILY.
Ten Commandments (cont’d)
6) Delirium is a medical emergency. Treat with
antipsychotics only when indicated.
7) Watch for depression.
8) Pay attention to amount of food consumed.
Consider supplements.
9) Start discharge planning with admission (and
remember to IDP the day before d/c)
10) Involve patient and family in decision-making
and advance directives.
DIAPPERS:
Transient Urinary Incontinence

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D-elirium
I-nfection (not asymptomatic bactiuria)
A- trophic Vaginitis
P-harmaceuticals
P-sychiatric
E-ndocrine
R-estricted Mobility
S- tool impaction
Resnick and Yalla N Engl J Med. 1985; 313(13):800-5.